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RESEARC H ARTIC LE Open Access
Long term follow up results of sequential left
internal thoracic artery grafts on severe left
anterior descending artery disease
Murat Mert
1*
, Gurkan Cetin
1
, Cenk Eray Yildiz
1
, Murat Ugurlucan
2
, Ilker Murat Caglar
3
, Ahmet Ozkara
1
, Atif Akcevin
1
, Cihat Bakay
1
Abstract
Purpose: Several alternative procedures have been proposed to achieve complete revascularization in the
presence of diffuse left anterior descending coronary artery (LAD) disease. With the extensive use of internal
thoracic artery grafts in coronary artery bypass procedures, sequential anastomosis of the left internal thoracic
artery (LITA) to LAD has gained popularity in these challenging cases. The long term results of sequential LITA to
LAD anstomosis were examined in this study.
Patients and Methods: In order to determine the long term results of the sequential revascularization of LAD by
LITA graft, 41 out of 49 patients operated between January 2001 and December 2005 were selected for control
coronary arteriography. The median period for control coronary arteriography was 64 months.
Results: Seventy five anastomoses were found to be fully patent (91,46%) among the 82 sequential LITA
anastomoses (41 LITA grafts) on the LAD at a median follow-up period of 64 months (53 to 123 months). Among

the 41 LITA grafts used for this purpose, 36 were found intact (complete patency of the proximal and distal
anastomoses) (87,8%). Two LITA grafts (4 anastomoses) were found to be totally occluded (4,87%). The proximal
anastomosis of the LITA graft was observed to be 90% stenotic in one patient (1,21%). In one patient tight stenosis
of the distal anastomosis line was observed (1,21%), while in another patient 70% narrowing of LITA lumen after
the proximal anastomosis was detected (1,21%).
Conclusion: We strongl y beleive that sequential LITA grafting of LAD is a safe alternative in the presence of severe
LAD disease to achieve complete revascularization of the anterior myocardium with patency rates not much
differing from conve ntional single LITA to LAD anastomosis.
Introduction
The primary goal in coronary artery surgery is the com-
plete revascularization with its proven superior long term
results [1]. However, in some patients, the usual coronary
bypass techniques may not allow a complete myocardial
revascularization due to the extent of the disease. In such
cases, complementary revascularization techniques may
bec ome mandatory especially if the diseased vessel i s the
LAD. In consequence, some alternative procedures, such
as the use of multiple or sequential anastomoses [2],
composite grafts [3], vein patch reconstruction [4] or cor-
onary endarterectomy [1] have been proposed to revascu-
larize the entire LAD system in the presence of diffuse
disease.
Among the alternative procedures, sequential use of
the left internal thoracic artery (LITA) is the pref erred
approach by our surgical team to overcome the diffuse
LAD disease. The purpose of this study is to report the
long term results of this procedure.
Patients and Methods
In order to determine the long term results of the
sequen tia l revascularization of LAD by a LITA graft, 41

out of 49 patients, operated between January 2001 and
* Correspondence:
1
Department of Cardiovascular Surgery, Instiute of Cardiology, Istanbul
University, Istanbul, Turkey
Full list of author information is available at the end of the article
Mert et al. Journal of Cardiothoracic Surgery 2010, 5:87
/>© 2010 Mert et al; licens ee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Common s
Attribution License (http://creativecommo ns.org/licenses/by/2.0), whi ch permits unrestricted use, distribution, and reproduction in
any medium, prov ided the original work is properly cited.
December 2005, were selected for control coronary
arteriography studies. Thirty one of the patients were
male where as 10 were female. Age ranged between 44
and 72 (59,2 ± 7,0) years. Hypertension, diabetes melli-
tus, hyperlipidemia, chronic obstructive pulmonary dis-
ease and positive family history were present in 43%,
46%, 58%, %17 and 21% of t he patients, respectively.
Active or previous cigarette smoking history was present
in 30 patients (73%). Pre-operative ejection fraction ran-
ged between 35% and 51% (41,4 ± 4,5%). Regular anti-
aggregant, lipid lowering or anti-ischemic medication
usage was inhomogenious and could not be clearly iden-
tified; however, all the patients were prescribed either a
calcium channel blocker or a beta-blocker, and aspirin
and a statin agent after the surgery. Patients operated
on emergent basis, operated on off-pump fashion, whom
requiring additional cardiovascula r procedures other
than coronary revascularization, and who have chronic
renal failure were excluded from the study.
In all patients, LITA was used to revasculari ze the

LAD sequentially in order to by-pass proximal and mid
portion stenoses in the artery. In addition to sequential
LITA anastomoses, 109 anastomoses were performed
with saphenous vein grafts (37 for the right coronray
artery, 43 for the obtuse marginal branches of the cir-
cumflex coronary artery and 29 for the diagonal branch
of the LAD). The demographic data of the patients are
presented on Table 1. The median period for control
coronary arteriography was 64 months (range 53 to 123
months).
Surgical technique
The sternum was opened via sternotomy incision. The
LITA was harvested with a large pedicle containing both
veins by the aid of electrocautery. Following systemic
heparinization, the LITA was transected after its bifurca-
tion and was kept in papaverine-soaked sponge until its
use. The cardiopulmonary bypass was initiat ed with aor-
tic and right atrial cannulations. Following a period of
cooling to 28-32°C, the aorta was cross-clamped and
cardiople gic arrest was established by cold blood cardio-
plegia infused through the aortic root and the coronary
sinus which was repeated every 20 minutes. First, the
saphenous vein distal anastomoses were performed and
followed by LAD arteriotomy between the estimated
proximal and mid-st enosis of this artery. 1,5 mm and
1 mm coronary artery probes were introduced distally
through this hole on the LAD and if the 1 mm prob e
could not be passed through the suspected mid LAD
stenosis, another arteriotomy was performed on LAD
distal to this stenosis region. Then, arteriotomy was

made on mid portion of LITA and at this region the
LITA was anastomosed side-to-side to the proximal
LAD where as the LITA end was anastomosed in an
end-to-side fashion to distal LAD sequentially bypassing
the stenoses. Care was carried to prevent bleedi ng from
LITA and from the distal LAD arteriotomy to check the
patency of the proximal LAD anastomosis. The aortic
clamp was then released and the proximal anastomoses
were performed during the re-warming period under a
partial aortic clamp. Following the wa rming period, the
patient was weaned off the cardi opulmonary bypass and
the chest was closed after completion of hemostasis.
Control coronary arteriography
The coronary arteriographies were performed after
explaining the aim in details and obtai ning patient con-
sent through the right femoral artery with Philips Integ-
ris H 3000 and Philips Integris HM 3000 C devices
equipped with Quinton monitorization systems (Philips
Company, Eindhoven, The Netherlands). All stenoses of
LITA greater than 50% were defined as “graft stenosis”,
and the non-visualization of the contrast material after a
certain point of the graft, at the anastomosis line or
non-filling of the host coronary artery, was defined as
“graft occlusion”.
Results
Post-operative period
There was no operati ve mortality among the 49 patients
operated during the study period. For the angiographi-
cally controlled 41 patients, the mean aortic cross-clamp
time was 79 ± 21,43 minutes and the mean cardiopul-

monary bypass time was 129,11 ± 33,23 minutes. The
mean number of distal anastomoses performed per
patient was 4,65 ± 0,62. One patient required intra-
aortic balloon pump assistance to wean off the cardio-
pulmonary bypass (2,4%). Two patients (4,8%) were
taken back to the operating theatre due to bleeding and
hemostasis was performed. Perioperative myocardial
infraction characterized by new Q wave appearance on
the postoperative electrocardiography was diagnosed in
one patient (2,4%) and was confined to the inferior bor-
der. Left sided pleural effusion was observed in two
Table 1 Demographic Data of the Study Group
Age (years): 59,2 ± 7,0 (range 44 to 72)
Male/Female: 31/10
Hypertension: 18/41 (43%)
Diabetes Mellitus: 19/41 (46%)
COPD: 7/41 (17%)
Hyperlipidemia: 24/41 (58%)
Family History: 9/41 (21%)
Cigarette Smoking: 30/41 (73%)
Pre-op EF: 41,4 ± 4,5% (range 35% to 51%)
COPD, Chronic Obstructive Pulmonary Disease; Pre-op, Pre-operative; EF, Ejection
fraction)
Mert et al. Journal of Cardiothoracic Surgery 2010, 5:87
/>Page 2 of 5
patients (4,8%) and was drained by pleural tube inser-
tion during the hospitaliza tion period. One patient
(2,4%) developed cerebrovascular event characterized by
left hemiparesia. All patients were discharged from the
hospital without any complications.

Follow-up period
All patients were called for clinical control by telepho ne
and coronary arteriography was proposed. Three
patients could not be reached. Two patients refused cor-
onary arteriography. There were 3 late deaths; 2 were
due to non-cardiac reasons (one patient died in a traffic
accident and the other fro m pancreatic malignancy).
The only cardiac death (2,4% ) occured in the 34th post-
operative month (sudden death). Thirty-five of 41
patients (85%) who accepted control coronary arterio-
graphy were in NYHA Class 1 functional capacity with-
out recurrence of angina. Five patients described
exertional dyspnea symptoms. One of them had already
undergone percutaneous transluminal coronary angio-
plasty (PTCA) of the native proximal LAD due to the
stenosis of the proximal LAD anastomosis. Another
patient had undergone PTCA of the native right coron-
ary artery due to the occlusion of the vein graft on this
artery. One patient was in NYHA Class 3 functional
capacity and was on anti-congestive medication against
heart failure.
Control coronary arteriographies
Seventy five anastomoses were found to be fully open and
patent (91,46%) among the 82 sequential LITA anasto-
moses (41 LITA grafts) on the LAD at a median follow-
up period of 64 months (53 to 123 months). Of the 41
LITA grafts used for this purpose, 36 (87,8%) LITA grafts
were found intact indicating a complete patency of the
proximal and distal anastomoses (Figure 1, Figure 2).
Two LITA grafts (4 anastomoses) were t otally

occluded (4,87 %). These patients were symptomatic and
a re-operation is offered. In one patient, the proximal
anastomosis of the LITA graft was 90% stenotic and this
patient had already been treated with PTCA and stent
implantation to the proximal LAD stenosis. In one
patient, tight stenosis of the distal anastomosis line was
observed (1,21%) while in another patient 70% narrow-
ing in the LITA lumen after the proximal anastomosis
was detected (1,21%). Medical treatment was decided
for these two patients who had negative myocardial per-
fusion scanning studies with anti-anginal therapy.
Discussion
The primary goal in c oronary artery surgery should be
the complete revascularization of all of the occluded or
stenosed coronary arteries that supply viable myocar-
dium with its best long-term results [3]. While the total
Figure 1 Control arteriography of a sequential left internal
thoracic artery to left anterior descending coronary artery
anastomosis supplying the septal branches proximally and left
ventricular apex distally. Control arteriography of a sequential left
internal thoracic artery to left anterior descending coronary artery
anastomosis supplying the septal branches proximally and left
ventricular apex distally.
Figure 2 Control arteriography of a sequential left internal
thoracic artery to left anterior descending coronary artery
anastomosis supplying the septal branches proximally and left
ventricular apex distally. Control arteriography of a sequential left
internal thoracic artery to left anterior descending coronary artery
anastomosis supplying the septal branches proximally and left
ventricular apex distally.

Mert et al. Journal of Cardiothoracic Surgery 2010, 5:87
/>Page 3 of 5
number of coronary artery revascularization procedures
decreases in the last years, the complexity and severity
of each procedure increases in this surgery population.
Cardiac surgeons are more and more confronted with
patients suffering from diffusely and severly calcified
coronary arteries [5]. In this patient population where
the possibilities of conservative coronary artery surgery
are limited, cardiac surgeons must add complementary
revascularization techniques to their armementarium in
order to offer these patients the benefits of complete
coronary revascularization.
When the severely diseased coronary artery is t he
LAD, the revascularization of the septal branches as well
as the apical part of the left ventricular myocardium
gains importance. Several techniques have been pro-
posed in the presence of an additional stenosis to the
proximal LAD stenosis in order to revascularize as
much possible as the anterior and apical parts of the left
ventricular myocardium. Since Bailey’sfirstcoronary
endarterectomy in the late 50’s [6], the procedure has
been the o nly weapon of the cardiac surgeons in these
difficult cases for a long period. Despite the facts that
higher rates of morbidity and mortality associated with
the procedure [7,8], the coronary endarterectomy still
keeps its place in these cases with improved results [5].
Extending the arteriotomy over the p laques on to th e
less diseased segments, so called long plaque-bridging
arteriotomy, is another alternative technique proposed

in diffuse LAD disease. Despite the good results
reportedwiththistechnique[9],weassumethatthe
graft patency might be impai red due to vascular wall
patholog y at the anas tomosis site. Similar to this techni-
que, long plaque-bridging arteriotomy of the LAD with
additional vein patch reconstruction before the anasto-
mosis is also an available technique in the presence of
severe disease [4]. In the last two decades, the excellent
results of LITA-LAD anastomosis, have made this graft
the golden standard for LAD revascularization. With
encouraging results of the LITA patency, a tendency to
extend internal thoracic artery usage with bilateral or
sequential internal thoracic artery techiques has become
more and more popular in recent years [10,11]. With
the pioneering efforts and excellent results of Tector
[12], sequential LITA grafting gained popularity in cor-
onary artery surgery and has become a very strong alter-
native in the presence of diffuse LAD disease.
At our department, sequential LITA a nastomosis for
severe LAD disease was advocated as the treatment of
choice since late 90’s. Over one hundred patients have
undergone this procedure until today. Our goal with
this technique is to revascularize septal branches of the
LAD as well as the apical part of the left ventricular
myocardium. In this particular group of patients with
severely diseased LAD, we primarily check whether the
diagonal artery to LAD connection is intact. In cases
where this connection is intact, simple revascularization
of the diagonal artery is usually effective to provide suf-
ficient retrograde blood flow to the septal arteries and

the distal stenosis of LAD is bypassed with another con-
duit. However, in cases where this connection is also
stenosed, the LAD is first opened distal to the proximal
stenosis and the severity of distal stenosis is judged
through this opening. If a 1 mm coronary artery probe
can not be advanced through this stenosis, the decision
is made for sequential LITA revascularization. Mid
LITA arteriotomy is performed and LITA to proximal
LAD anastomosis is achieved in side to side fashion.
Before the construction of the distal anastomosis, judge-
ment of the flow from the distal end of the LITA and
some bleeding from the distal coronary arteriotomy is
critical to decide for the patency of the proximal anasto-
mosis. In these patients, when the decision is sequential
LITA grafting, we routinely begin intravenous nitrogly-
cerine and diltiaze m infusions and continue for two
days, then the patien t is followed with diltiazem for
three months to attenuate LITA vasospasm risk.
As in our group, many other authors have also sug-
gested that sequential LITA anastomoses as the best
method to revascularize the LAD system which is dis-
eased at multiple segments[1,13]). Although, endarter-
ectomy is anothe r option in such cases, we also believe
that sequential LITA grafting to be a less invasive, safe
and a more effective procedure in every possible
patients, when compared to endarterectomy with its
morbidity and mor tality rates reaching significant differ-
ences in some reports especially when performed on th e
LAD [4,7,14].
The results of our study are also unique in being one

of the largest series and provid ing the longest follow-up
data in the litterature on this topic. The data and results
obtained from the study are in accordance with other
sequential LITA bypass studies [1,2,15] and are promis-
ing to research the behavior of sequential LITA only on
the LAD. The results of sequential LITA to LAD ana-
stomosis are similar to that of single LITA to LAD ana-
stomosis (91,48 % at a median follow- up period of 64
months) or even better and we did not observe a signifi-
cant patency difference betwe en the proximal and distal
anastomoses. Additionally, we did not encounter any
LITA hypoperfusion problem due to sequential use and
we believe that t he large coronary reserve in LITA
sequential grafts may contribute to an improved long-
term patency [16].
In the literature it has been shown that sequential
bypass grafting has some advantages over the classical
single bypasses. These are decreased impedance mis-
match, decreased resistance to graft flow, and econom-
ical usage of the valulable grafts [2,17]. It is well
Mert et al. Journal of Cardiothoracic Surgery 2010, 5:87
/>Page 4 of 5
documented that sequential grafting yields higher
patency rates, especially when it is performed to small
caliber and/or poor quality coronary arteries with poor
run off [2,17,18]. Evidence may suggest that, distribution
of inflow to multiple distal run offs may aid patency of
the conduit especially when it is anastomosed to a poor
target.
In conclusion , we strongly be leive that sequential

LITA grafting of LAD is a safe alternative in the pre-
sence of severe LAD disease to achieve a complete
revascularization of the anterior myocardium with
patency rates not much differing from conventional sin-
gle LITA to LAD anastomosis.
Acknowledgements
Authors would like to thank Ms. Jacqui Arnott for the linguistic revision of
the manuscript.
Author details
1
Department of Cardiovascular Surgery, Instiute of Cardiology, Istanbul
University, Istanbul, Turkey.
2
Department of Cardiovascular Surgery, Duzce
Ataturk State Hospital, Duzce, Turkey.
3
Department of Cardiology, Duzce
Ataturk State Hospital, Duzce, Turkey.
Authors’ contributions
MM, GC, CEY, AO act in data collection. MM, GC, CEY, MU, IMC, AO act in
data interpretation and manuscript writing. MM, GC, MU, AA, CB act in study
design and ciritical revision of the manuscript. All authors approved the final
manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 25 August 2010 Accepted: 19 October 2010
Published: 19 October 2010
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doi:10.1186/1749-8090-5-87

Cite this article as: Mert et al.: Long term follow up results of sequential
left internal thoracic artery grafts on severe left anterior descending
artery disease. Journal of Cardiothoracic Surgery 2010 5:87.
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